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<form action="${domain}/admin/fifth/e" method="post"  onsubmit="return checkForm()">
    <div align="center" width="1000px">
        <td><input name="oName" type="hidden" value="${oName}"></td>

        <h4>表6  2016年自费疫苗情况调查表</h4>

        <table border="1" cellspacing="0" cellpadding="0">
            <tr>
                <td >疫苗名称</td>
                <td>品规</td>
                <td>接种数量（人次）</td>
                <td>接种单价（元）</td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=fifthE[0] value="甲肝疫苗" type="hidden">甲肝疫苗</td>
                <td><input name="fifthE[1]"></input></td>
                <td><input name="fifthE[2]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[3]" type="number"  step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=fifthE[4] value="乙肝疫苗" type="hidden">乙肝疫苗</td>
                <td><input name="fifthE[5]"></input></td>
                <td><input name="fifthE[6]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[7]" type="number"  step="0.01"></input></td>
            </tr>

            <tr>
                <td><input readonly unselectable="on" name=fifthE[8] value="乙脑疫苗" type="hidden">乙脑疫苗</td>
                <td><input name="fifthE[9]"></input></td>
                <td><input name="fifthE[10]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[11]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[12] value="流腮疫苗" type="hidden">流腮疫苗</td>
                <td><input name="fifthE[13]"></input></td>
                <td><input name="fifthE[14]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[15]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[16] value="HIB疫苗" type="hidden">HIB疫苗</td>
                <td><input name="fifthE[17]"></input></td>
                <td><input name="fifthE[18]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[19]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[20] value="23价肺炎疫苗" type="hidden">23价肺炎疫苗</td>
                <td><input name="fifthE[21]"></input></td>
                <td><input name="fifthE[22]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[23]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[24] value="水痘疫苗" type="hidden">水痘疫苗</td>
                <td><input name="fifthE[25]"></input></td>
                <td><input name="fifthE[26]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[27]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[28] value="轮状疫苗" type="hidden">轮状疫苗</td>
                <td><input name="fifthE[29]"></input></td>
                <td><input name="fifthE[30]" type="number"  step="0.01"></td>
                <td><input name="fifthE[31]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[32] value="IPV活脊灰疫苗" type="hidden">IPV活脊灰疫苗</td>
                <td><input name="fifthE[33]"></input></td>
                <td><input name="fifthE[34]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[35]" type="number"  step="0.01"></input></td>
            <tr>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[36] value="流感疫苗" type="hidden">流感疫苗</td>
                <td><input name="fifthE[37]"></input></td>
                <td><input name="fifthE[38]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[39]" type="number"  step="0.01"></input></td>
            <tr>
                <td><input readonly unselectable="on" name=fifthE[40] value="狂犬疫苗" type="hidden">狂犬疫苗</td>
                <td><input name="fifthE[41]"></input></td>
                <td><input name="fifthE[42]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[43]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[44] ></td>
                <td><input name="fifthE[45]"></input></td>
                <td><input name="fifthE[46]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[47]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[48] ></td>
                <td><input name="fifthE[49]"></input></td>
                <td><input name="fifthE[50]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[51]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[52] ></td>
                <td><input name=fifthE[53] ></td>
                <td><input name=fifthE[54]  type="number"  step="0.01"></td>
                <td><input name="fifthE[55]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[56] ></td>
                <td><input name="fifthE[57]"></input></td>
                <td><input name="fifthE[58]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[59]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[60] ></td>
                <td><input name="fifthE[61]"></input></td>
                <td><input name="fifthE[62]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[63]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[64] ></td>
                <td><input name="fifthE[65]"></input></td>
                <td><input name="fifthE[66]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[67]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[68] ></td>
                <td><input name="fifthE[69]"></input></td>
                <td><input name="fifthE[70]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[71]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[72] ></td>
                <td><input name="fifthE[73]"></input></td>
                <td><input name="fifthE[74]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[75]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[76] ></td>
                <td><input name="fifthE[77]"></input></td>
                <td><input name="fifthE[78]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[79]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[80] ></td>
                <td><input name="fifthE[81]"></input></td>
                <td><input name="fifthE[82]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[83]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[84] ></td>
                <td><input name="fifthE[85]"></input></td>
                <td><input name="fifthE[86]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[87]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[88] ></td>
                <td><input name="fifthE[89]"></input></td>
                <td><input name="fifthE[90]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[91]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[92] ></td>
                <td><input name="fifthE[93]"></input></td>
                <td><input name="fifthE[94]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[95]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[96] ></td>
                <td><input name="fifthE[97]"></input></td>
                <td><input name="fifthE[98]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[99]" type="number"  step="0.01"></input></td>
            </tr>
            <tr>
                <td><input name=fifthE[100] ></td>
                <td><input name="fifthE[101]"></input></td>
                <td><input name="fifthE[102]" type="number"  step="0.01"></input></td>
                <td><input name="fifthE[103]" type="number"  step="0.01"></input></td>
            </tr>
        </table>
        <p align="left">
            注：</br>
            1、疫苗范围包括免疫规划内收费疫苗与计划外疫苗，同一疫苗涉及多个剂型、厂商的，可作为不同品规分别填报。</br>
            2、接种单价包括接种费和疫苗费。</br>
            3、如本机构无某一疫苗的接种，请在对应的单元格中填横线。</br>
            4、表中没有列出的疫苗，请在空行中补充。</br>
        </p>
        <button type="submit" ><b>提交并进入下一表格</b></button>


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